NEW YORK - BILLING ISSUES

1. May a physician charge for missed appointments?

There is no general restriction that prohibits physicians from charging for missed appointments. It is advisable, however, to provide patients with prior notice concerning billing arrangements and procedures.

Note: The physician should be aware of any restrictions on this prohibition imposed by a patient's managed care program.

There is no general restriction that prohibits physicians from charging late fees and interest on unpaid balances. It is advisable, however, to provide patients with prior notice concerning billing arrangements and procedures.

Note: The physician should be aware of any restrictions on this prohibition imposed by a patient's managed care program.

3. What restrictions on billing apply to physicians?

A. Physicians should be aware that there are statutory restrictions that affect the ability of physicians to charge such fees:

1. The Insurance Law prohibits physicians from charging fees in excess of the charges permissible under the Workers' Compensation Board Fee Schedule for services rendered as a result of an injury and for service which are in excess of basic economic loss as defined in by Insurance Law 5102.

(Insurance Law § 5108 (a); See also 11 N.Y.C.R.R. 65, et. seq.)

2. The Public Health Law prohibits physicians from charging fees in excess of the charges permissible under Title XVIII of the Federal Social Security Act (Medicare).

(Public Health Law § 19)

Of course, bills must accurately reflect the services provided, the correct CPT codes and any other information to avoid being misleading.

4. Is a physician required to provide a patient with an itemized bill?

A patient in a hospital has the right to receive an itemized bill. New York has no regulation governing the provision of an itemized bill to patients of private practices, other than in the Workers' Compensation Law.

(10 N.Y.C.R.R. 405.7 (c)(16))

5. Is a physician required to maintain copies of billing records?

Although there is no requirement to maintain copies of billing records, a physician should maintain records of billing and reimbursement transactions for a minimum of six years from the date of receipt of payment in the event of an insurance audit. Pursuant to the statute of limitations on contract claims, insurance companies may evaluate claims as old as six years.

Physicians who render services to beneficiaries of Medicare and certain to private insurance companies should retain financial records for at least ten years. Government programs and some private insurance companies require providers to maintain records for longer periods of time. Also, under the False Claims Act, the Center for Medicare and Medicaid Services can pursue a claim against a medical provider for the filing of a false or fraudulent claim as long as 10 years after a claim for medical benefits has been filed. For all of these reasons, medical records should be maintained as long as recommended to protect the physician's interests.

(C.P.L.R. § 213(2); 31 U.S.C. § 3731 (b)(2))

5. May a physician charge for filling out medical insurance forms?

Apparently, yes. According to the Department of Education, it is professional misconduct for a physician to fail to complete forms or reports a patient requires in order to receive reimbursement by a third-party. This same provision indicates that a reasonable fee may be charged for the completion of such forms or reports.

(Education Law § 6530 (43))

7. What Factors which may be considered in determining whether a fee is excessive?

A. The time and effort required;

B. The novelty and difficulty of the procedure or treatment;

C. The skill required to perform the procedure or treatment properly;

D. Any requirements or conditions imposed by the patient or by the circumstances;

E. The nature and length of the professional relationship with the patient;

F. The experience, reputation and ability of the licensee performing the services;

G. The nature and circumstances under which services are provided. Unless services are provided during an emergency or other circumstances where opportunity, custom and practice will preclude discussion prior to the rendition of such services, the licensee shall, in advance of providing services, specify or discuss and agree with the patient, the fee or basis for determination of the fee to be charged.

8. Are their any penalties for excessive billing?

Charging an excessive fee could be determined to constitute moral unfitness to practice medicine. Such conduct constitutes professional misconduct, which could subject the licensee to disciplinary action by the New York State Department of Health.

(Education Law § 6530 (20))

Copyright Kern Augustine Conroy and Schoppmann, P.C. Used with permission.